1. Patient Presentation History of Present Illness (HPI)-
55 y.o. alert, married female presents to ED with cc: acute lower abdominal pain x 3-4 days, worse last 1-2 days, now sharp, severe, cramping.
Pain 10/10 on 0-10 scale; Pain temporarily better with “tums”
S/S: + n/v; “bloated”; constipation; + rectal bleeding
c/o urinary frequency/urgency/dysuria x 2 days

2. Patient Presentation Past Medical History (PMH)
Obesity (5’6”, 130kg);DM type 2; HTN; Hyperlipidemia; Hiatal hernia; IBS; Hemorrhoids
Past Surgical History (PSH)
Appendectomy (age 17)
Total Hysterectomy (age 40)
T & A (age 7)
Nml colonoscopies x3; last one 2 years ago.
Previous admissions-
Pt had ED visit 6 weeks ago for flare up of IBS.

3. Patient Presentation Family Hx- Social Hx- Married x 30 years
2 grown children; 4 grandchildren; all healthy
Both parents deceased: Mother(lung ca); father (prostate/colon ca).
Social Hx-
No tobacco > 25 years
No alcohol (1-2x/year)
No recreational drugs

4. Patient Presentation Current Medications- Medication Allergies-
Lisinopril 10mg po QD (HTN); Lipitor 20mg po QD (chol); Metformin 500mg BID (DM); Fish Oil 1000mg TID(cardiac health); MVI 1po QD; Bentyl 10mg po QID – prn (IBS); Ca+, Mg+, Zinc combo vitamin po QD (women’s health); ASA 81mg po QD (heart health).
Medication Allergies-
PCN (rash); Codeine (n/v)

5. Patient Presentation Physical Exam (PE)- Labs-
VS: T 37.1, HR 90, RR 20, BP 130/65, SaO2 99%RA
Gen: A/O x 4; moderate distress, speaks in full sentences, amb without assistance.
CV: RRR, no murmurs
Pulm: CTA b/l, no wheezes
Abd: soft, distended, + BS; TTP LLQ, no rebound, + guarding; small mass palpated LLQ.
Ext: 2+ DP pulses b/l, no cyanosis, no rash
Rectal: Heme stool neg.; external hemorrohoids noted, no acute inflammation/tenderness/blockage or blood.
Labs-
WBC: 11.3 (mild leukocytosis), Hct. 33.9, Plts 290, INR 1.2, BMP WNL, UA neg.

6. References
National Digestive Diseases Information Clearinghouse website. (2008).
Up to Date Online 18.3 website. (2010).